Should your hospital allow C-sections on demand?
Increasingly, mothers are opting for surgery
As concerns about the rising rates of cesareans grow, obstetricians across the country are reporting an unusual phenomenon: pregnant women are asking to schedule cesarean deliveries, even though their doctors see no reason to perform one.
What some childbirth advocates are decrying as dangerous practice, some see as a matter of patient autonomy. With the risk of serious injury or death very low for either vaginal birth or an uncomplicated cesarean, why shouldn’t doctors let the patients choose?
"The pendulum certainly has swung in obstetrical care and the concept of natural birth," says Adelaide Nardone, MD, FACOG, a practicing obstetrician in upstate New York, and medical consultant for the Vagisil Women’s Health Center. "Not many years ago, women would seek out OB/GYNs that were notorious for their low section rate. In fact, many patients would ask me what my personal C-section rate was. If it was less then 20%, this was often considered desirable. Today, women are demanding the complete opposite. Now an elective C-section is in vogue, and women are demanding them all over."
Several factors are fueling this new preference, Nardone says. Newer studies have examined the possibility of pelvic floor dysfunction, uterine prolapse, and incontinence as a result of vaginal birth, and many women seek a cesarean to prevent this from occurring.
There also have been more reports of cases of uterine rupture during vaginal births after cesarean (VBAC), and this has alarmed many women and physicians alike.
"Over time, more and more women have opted for epidural and analgesia during labor and delivery as the drug-free natural birth concept is not so popular with women in labor these days," Nardone adds. "In fact, the fear of labor and delivery has left many women wanting to avoid the whole experience and just get it out’ via the knife."
More women are having babies later in life and through reproductive technology. They may have fears about complications during labor and delivery that do not warrant them taking any chances and they may prefer a section.
An editorial published two years ago by W. Benson Harer, MD, then the president of the American College of Obstetricians and Gynecolo-gists (ACOG) supporting the right of women to choose the procedure has added fuel to the fire, adds Bruce Flamm, MD, FACOG, a professor of obstetrics and gynecology at the University of California-Irvine, and a member of the ACOG board.
"That lent a lot of weight to the issue, because he supported it," Flamm says. "But many of the arguments had been going on before that."
What has changed is not so much the number of patients asking for the procedure as the number of OB/GYNs willing to do a primary elective cesarean, he says.
"The concept is not new. Anyone who has ever practiced obstetrics has had women, particularly those in labor, tell us, Take my baby now.’"
Now some obstetricians will take that woman to surgery without any medical indication for the procedure.
"During the shift from the older, more paternalistic view of medicine to the shift to one more tolerant of patient choice, it has become more serious," he says. "People are taking it very seriously, to the point that even if a woman is not in labor and it is two weeks before her due date, she can say, I want a cesarean section,’ and some doctors will just do it. That was absolutely unheard of until the last couple of years."
While the rates of cesarean section went down during the 1990s, they have been headed back up again. Many clinicians expect the cesarean rate to hit an all-time high this year, with approximately a quarter of all births performed this way.
"The rate in America peaked at just under 25% in 1988 at about 24.5%," he says. "Then, largely to an emphasis on natural childbirth and VBAC, it fell for a decade. Now the rates are on their way back up. Preliminary data for 2001 put the national rate about 24%. And I think we are going to see more and more cesareans on demand."
Which is riskier?
Obviously, both vaginal birth and cesarean carry risks, Flamm says. But with modern advances in obstetrical care, the chance that a healthy woman will die or suffer serious medical complications from either procedure is very low.
Existing clinical studies comparing the risks of cesarean with vaginal birth mostly only compare women who give birth vaginally with women who have a cesarean because of a medical problem — not a true comparison of the risks.
"There have been many studies that tried to look at this issue in retrospect. The problem is you are comparing apples to oranges," he explains. "Thirty or 40 years ago, the studies showed a huge increased risk with C-section. Some showed a twenty- to thirtyfold increased risk of maternal death with cesarean. But when you go back and look at why they had a cesarean, death may have had more to do with the mother’s medical condition. If a mother comes to the emergency room bleeding, and an emergency C-section is done and she dies, is that a result of the surgery or a result of her medical emergency in the first place?"
Older studies likewise show an increased risk for the baby if a cesarean is performed, but this is largely attributed to iatrogenic prematurity or "taking the baby too early," Flamm explains. "With the advances of ultrasound and other ways to determine gestational age, there is much less chance of that happening now."
More recent studies have shown a lower, but still increased risk of complications from surgery, says Flamm. "Some people argue that there is no real increased risk, but I don’t know if we can say that for sure."
Vaginal birth also carries some risk, but that is true of almost anything, he adds.
"I would never tell a woman who comes to my office, Oh, no; you heard wrong. There is no risk. There are risks any time you go in and have a baby, whether a C-section or a vaginal birth. And there are risks to the baby both with a cesarean section and with labor."
Should hospitals make a policy?
Doctors are divided on whether this issue should be decided at the managerial or administrative level, say both Nardone and Flamm.
"This is an emerging issue right now. This is not something that has been going on for 15 or 20 years," Flamm says. "A lot of people have not reached the point of developing policies. I would venture to say the vast majority of hospitals do not have specific policies on cesarean on demand."
Although many doctors may feel that the decision should not be up to administrators or HMOs or insurance companies — that it should be left in the hands of the patient and physician, it may be important for hospitals to have policies in order to establish a standard of care.
"There is an advantage to having a uniform method of practice," he advises. "If you have 20 doctors who practice at a hospital and they get together and review the literature and come to a decision and make a policy that way, it may be helpful in that patients can be presented with a uniform view."
Currently, Flamm advises women seeking an elective cesarean section of all of the risks and benefits for both vaginal birth and surgery, as he sees them. So far, none of his patients have chosen to have a primary, elective cesarean.
"Really, when women have come to me to discuss this issue, it is because they fear that labor is going to be a disaster," he says. "They fear it is going to be the worst pain they’ve felt in their lives; they will betray their whole family by screaming in the delivery room. Once we address these issues and talk about how we can help them with pain medication, at least in my practice, women have been willing to give labor a try."
It’s important that women who are fearful of the pain and danger of labor also understand the risks associated with major surgery, Nardone notes.
"Like any medical issue, it has its risks and benefits," she emphasizes. "Women need to know and realize that there is still is inherent risk in this surgical procedure. The recovery is usually longer and more painful. There is always the chance of taking the baby too early, or some anesthetic or infectious complication. The women may need to have repeated C-sections with each pregnancy in the future. The baby can even be injured with the scalpel or the mother could have a surgical complication, etc."
In light of these issues, each case has to be individualized, she states.
But there also should be policies and procedures, and guidelines in place for obstetricians to follow as the standard of care, she adds.
"And women need to sign waivers of refusal to have vaginal delivery after an informed discussion on this matter has transpired," Nardone says. "No one can force a woman to do something she does not want to do. But, decisions need to be made based on the patients’ needs and what serve their best interest."
For further reading
- Harer WB. Quo vadis cesarean delivery? Obstet Gynecol Survey 2002; 57:61-64.
- Goer H. The case against elective cesarean. J Perinatal Neonatal Nurs 2001; 15:23-38.
Source
- John E. Wennberg, MD, David C. Goodman, MD, Center for the Evaluative Clinical Sciences at Dartmouth, Hanover, NH 03755. Web site: www.dartmouth.edu/~dms/cecs/.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.